Study of causes of persistent acute malnutrition in north Darfur

Summary of study¹

Children and their caregivers enrolled in the BSFP

In spite of national and international efforts to manage the devastating impact of the conflict in Darfur which began in 2003, children in different parts of the region have consistently demonstrated high levels of global acute malnutrition (GAM) often exceeding the WHO emergency threshold of 15%. This has been found in areas where the food security situation appears to be ‘good’ according to the regional food security monitoring system (FSMS) established by the World Food Programme (WFP).

WFP recently conducted a study to shed light on this situation. The main objectives of this study were to investigate the underlying causes of acute malnutrition in North Darfur State, specifically in Kabkabyia town where the study was conducted, and to suggest feasible and realistic recommendations to address these that would guide future interventions and programmes.

Context

Kabkabyia was selected as it had experienced a high GAM rate (>15%) among children under 5 years for the past five years, while the FSMS indicated that the town was relatively better off in terms of food security compared to other areas in North Darfur.

Kebkabiya town is located in the southwest of North Darfur State approximately 165 km from El Fasher, the capital of the state. The town is divided into 16 quarters, which are themselves divided into several sub-quarters. Following the first major attacks on rural Kebkabiya and Jebel Si in July 2003, there was a huge influx of internally displaced persons (IDPs) into Kabkabyia town.

Currently, it is estimated that 119,793 individuals are living in the town, with IDPs accounting for almost 70-75% of the population. Up until the start of the conflict in 2003, Kebkabiya was known as a central trading point for agricultural products such as cereals, vegetables, fruits, and oleaginous plants cultivated in Kebkabiya and Jebel Si. The town was also known as a trading point for livestock such as sheep, goats, cattle from nomads, and for non-food items from El Fasher city.

The unstable security situation in Kabkabyia in recent years has limited people’s access to agricultural lands. Since the onset of the conflict in the region, WFP has been providing Kabkabyia residents, including the IDPs, with food aid in the form of a general food ration (GFD). This aid, which is distributed once every 60 days, initially met 100% of the kcal requirement of the IDPs. With an improved food security situation over several years, the GFD ration was reduced in 2010 to provide 50% of the requirements (1200 kcal). Other food aid interventions such as food for education, food for work, blanket supplementary feeding programmes (BSFP), and food rations for households with malnourished children, e.g. supplementary feeding programmes (SFPs), have also been implemented. The FSMS data indicated that the decreased GFD ration did not adversely affected household food security.

Study site and group

El-Salaam area was selected as the study site in Kabkabyia town as it had the second highest population density and the highest GAM rate in the town (>21% according to a May 2010 survey). El-Salaam area is composed mainly of IDPs who live outside of camps but are not living with relatives in the town.

For the purposes of the study, a household was defined as a group of people who routinely ate out of the same pot and lived in the same compound or physical location. In order to satisfy the objectives of this study, selected households had to be located in El-Salaam area in Kabkabyia town and have a child between 6- 23 months of age.

Selected households were then organised into three clusters based on children’s nutritional status:

Cluster A: children suffered no acute malnutrition at the time of conducting this study, i.e. children were well-nourished with +1 WHZ or above.
Cluster B: children suffering from moderate acute malnutrition at the time of conducting this study with a WHZ between -2 to -3.
Cluster C: children suffering from severe acute malnutrition at the time of conducting this study based on their WHZ score assessment, which was <-3.

Study findings

The households in all three clusters were found to eat at least three meals per day. Food aid was reported to be consumed by a larger number of people than indicated by the ration cards shown to the study team. As a result, food aid reportedly only lasted between 20-30 days instead of the planned 60 days.

All of the households in clusters B and C, and a few households from cluster A, experienced food shortage several times during the year. Food shortages were also frequently experienced in all households that did not cultivate land, which was more prevalent in clusters B and C than in cluster A. Most affected households responded to food shortages by eating less favoured foods that were cheaper and of lower nutritional value, reducing the number of meals and portion size, as well as borrowing food and money. In addition, household heads also worked to generate income.

The study found that children started breastfeeding a few hours after birth and that most of these children were still breastfeeding during the time of the interviews. Complementary feeding for all the children in this study started at the age of 6 months².

All households in the three clusters spent most of their income (more than 50%) on purchasing food. Earned income was also spent on purchasing firewood and paying for medical services in addition to food to supplement the GFD. In clusters B and C in particular, data suggested that households’ adults who could work, would only seek work when there was no food and/or money in the households.

Water sources for all households in the three clusters came mainly from the hand pumps and water tanks, depending on which water source was nearer to the households. Enough water for all the households was collected in plastic jerkins everyday and each jerkin contained about 20 litres of water. Water samples were taken for testing from all households included in this study. These samples were positive for contamination for different types of bacteria such as Cirtobacter, Klebsiella, E.coli, Salmonella and Vibrio.

For most of the households, latrines were present outside of the household and were donated by aid organisations. Each latrine was used by 2-5 households. Mothers in all households mentioned that they would wash children’s hands several times during the day and would bath these children regularly. Mosquito nets and blankets were not observed in most of households, particularly for households in cluster B and C.

Most households in cluster A were found to have been engaged in agricultural activities on their own land during the last rainy season where they cultivated mainly millet. Households in clusters B and C did not cultivate land which made these households dependent on food aid and on purchase of food from the local market.

Cluster A households ate a wider variety of food items in the two weeks prior to conducting the interviews when compared to households in cluster B and C during the same period. In cluster A, food types consumed included cereals, sugar, cooking oil, dry and fresh meat, milk, biscuits, dry okra, fresh vegetables, and sometimes fruits. In comparison, households in clusters B and C were found to have rarely consumed fresh meat, vegetables and fruits.

Children in cluster A were between the ages of 7-22 months and were found to have been fed more frequently i.e. between 3-4 times, when compared to children in clusters B and C who were fed between 2-3 times a day. Children in cluster B and C were mainly fed asida and poor quality molah made of dry meat, dry okra and kawal.

Heads of households in cluster A were found to have more access to regular sources of income and were either receiving monthly salaries from regular employment or owned small business which provided regular sources of income all year as well as access to cultivation. The household heads of cluster B and C depended on seasonal employment opportunities. These household reported experiencing money shortage and subsequently food shortage frequently during the year.

Water consumption/uses in all households seemed to be adequate. Differences between the three clusters were mainly in water uses/quality/hygiene. Observation of water containers, especially water jerkins, from all households in cluster A looked clean unlike most jerkins from cluster B and C.

Interview results suggest that left-over food was not consumed by the targeted children in most of the cluster A households. The few households in cluster A which fed targeted children left-over, reported feeding children the leftover food only after reheating. They also reported food was consumed shortly after it was prepared/reheated. These ‘good’ food handling practices were not prevalent in the other two clusters, where left over food was often fed to the targeted children.

Mothers from all households in cluster A reported washing their hands with soap and water more frequently during the day, 7-10 times, compared to mothers in clusters B and C who used to wash their hands only between 5-6 times. Soap consumption was reported to be more prevalent in households in cluster A than in households in clusters B and C.

All children in cluster A where found not to have not experienced any illness such as diarrhea, vomiting, fever or common cold within the last 30 days prior to conducting of the interviews for this study. On the other hand, all children included in Clusters B and C were sick with diarrhoea, vomiting and fever within the last 14 days prior to conducting of the interviews. Food consumption of children in these clusters during the illness period was described as very poor. Mother reported that these were children mainly dependent on breastfeeding during the bouts of illness. These findings were more evident in cluster C (severely malnourished children).

Discussion and Recommendations

Although the sample size of households included in this study was small and therefore, findings cannot be generalized to the larger population in Al-Salaam area or Kabkabyia town these findings are still useful for planning purposes.

Findings suggest that agencies should consider job creation interventions, e.g. income generating activities, that would lift vulnerable populations out of poverty. Training on proper finance management at the household level should also be considered in an effort to change the noted culture of "I only need to look for work when there is no money or food in the house".

It is also important to look at the adequacy of food aid rations received by displaced people. The study finds a significant discrepancy between number of people living in a household with the number registered on the ration card, so that the ration does not last as long as planned. The ongoing re-verification exercise of the IDPs in Darfur should help in addressing such discrepancies and should also assist WFP in determining which household are more vulnerable than others and therefore allow for provision of food aid required accordingly.

There is also a need for more education and awareness raising programmes around issues of hygiene and sanitation, as well as more provision of soaps/detergents or water purifiers as necessary to the households.

The issue of soap shortage in most of the households with malnourished children should also be addressed. This can be done through increasing the soap ration received, which should be linked to the results of the proposed verification exercise in order to properly match the number of people actually living in the household with the number of soap bars to be received.

There also needs to be awareness raising activities for mothers and child caregivers regarding symptoms and management of child malnutrition with an emphasis on child feeding practices.

²Methodology and age of children investigated not reported for this indicator.

¹WFP (2011). Study report. Causality study on causes of persistent acute malnutrition in north Darfur (Kabkabyia) 2010-2011. Report prepared by Insaf Ibrahim for WFP Sudan.